Will Smokers With COVID-19 Be Denied Ventilators? Doctors Do Not Want To Operate On Smokers: There’s Long-Standing Medical Precedent, And Strong Arguments, Says Expert
WASHINGTON, D.C. (April 7, 2020) – If a hospital has to temporarily ration the use of ventilators for COVID-19 patients in respiratory distress, as hospitals did in Italy, and as some hospitals are reportedly planning to do in New York, some wonder if smokers will be among those left out.
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The Trend Of Doctors Are Refusing To Operate On Smokers
Actually, there is long-standing precedent in many countries for refusing to operate on smokers, even when the need is very great, and persuasive arguments for disfavoring them when it comes to ventilators, claims public interest law professor John Banzhaf, who has studied and written about the phenomena for many years.
For example, a professional ethicist has just written that "a New York hospital could choose to give its last ventilator to the 72-year-old marathon runner rather than to the 57-year-old pack-a-day smoker." The ethicist cites a New York protocol titled "Allocation of Ventilators in a Public Health Disaster" which proclaims that "prognosis for recovery," rather than age or other factors, should be the criterion for choosing who is to be left to die if ventilators run out.
The Charlotte Observer recently reported that "doctors are refusing to operate on smokers in some cases [and] here's why the trend will grow." Actually, notes Banzhaf, that "trend" has been going on for many decades, it has been approved by ethics boards, and the policy has been adopted even in countries where government health care is guaranteed by law.
For example, doctors at Wythenshawe Hospital in Manchester, England, have refused to carry out heart by-pass surgery on smokers for some fifty years, except in emergencies. Doctors at Leicester, Leeds and Newcastle upon Tyne follow the same policy, The UK is not alone in having such a policy.
For example, when reports surfaced that a surgeon in Northern Ontario, Canada, was refusing to operate on smokers, Ontario's medical watchdog, the College of Physicians and Surgeons, ruled that he and other doctors within the province were within their rights. Then the Ontario Medical Association backed his decision.
Restrictions On Smokers
The rationale for refusing to operate on smokers was spelled out more than 10 years ago in an article in a 2007 report in MEDICAL WORLD TODAY about the Leicester City Primary Care Trust's policy, which it said is "expected to spread quickly throughout the country." Here's what that medical publication reported ten years ago:
"The new restrictions are set to begin this summer in the UK, initially under the Leicester City Primary Care Trust, but the requirements are expected to spread quickly throughout the country. Under the rules, smokers are to be denied operations under the Health Service unless they give up cigarettes for at least four weeks beforehand, and doctors will require patients to take a blood test for nicotine residue to prove they have not been smoking. Medical research shows that smokers take far longer, on the average, to recover from operations, and are far more likely to suffer serious medical complications. This not only greatly increases the cost of providing surgery to smokers, but also ties up beds and hospital facilities urgently needed by other patients."
"The Trust says that 'if people give up smoking prior to planned operations it will improve their recovery. It would reduce heart and lung complications and wounds would heal faster.' Thus it is a 'perfectly legitimate clinical decision.'"
Severe Consequences Of The Policy
Similarly, today, in about a third of the UK, smokers are often denied surgery for an indefinite period of time if the surgery is judged to be routine or non-urgent. To obtain the surgery, smokers must first go for 8 weeks or more without a cigarette, and then also take a breath test to prove their compliance.
In many cases the consequences of the policy can be very severe. For example, just last year a mother of 2, in need of an "urgent" operation to remove three large gallstones which had become infected and were causing her "immense pain," was told that she would have to remain in pain for 6 months and quit smoking if she wished to have the operation.
Also, even in situations in which a surgeon is willing to operate, the procedure can be effectively denied if the insurance company refuses to pay the huge costs because the patient is a smoker. This happened to a Virginia man with spinal stenosis who was informed, only 48 hours prior to scheduled surgery designed to correct his condition, that his medical insurance would not cover it.
Even where lives are very clearly at stake, smokers may be denied critical operations.
For example, the University of Utah Hospital has a policy which generally does not permit organ transplants - even life-saving ones - to patients with active tobacco (and other) dependencies. In at least one tragic example of the consequences of that policy, a 19-year-old patient was denied a lung transplant and died shortly thereafter as a result.
Post-Operation Complications
A report this year from the W.H.O. showed that smokers who undergo surgery have more than double the rate of post-operation complications. The authors said that this finding alone provided a powerful case for doctors to delay elective surgery for smokers to allow them more time to quit.
Banzhaf notes that the much higher risks of surgery to patients who smoke occur even if the procedure don't involve lungs or breathing; e.g., a broken leg sustained by a healthy young skier. Thus, since a major cause of death among COVID-19 patients involves the lungs and an inability to breathe, the risks to COVID-19 patient who is a smoker are likely to be much greater, and the chances of survival much lower, suggests Banzhaf.
As he has repeatedly reported, even light or occasional ("social") smoking damages the lungs and reduces the ability of the lungs to extract oxygen from the air, so even otherwise young and healthy smokers are more likely to die or suffer permanent and possibly incapacitating damage to their lungs or brains (from temporary deprivation of necessary oxygen) than nonsmokers.
Will Doctors refuse to operate on smokers
Indeed, as WebMD explains, "smokers and vapers who get COVID-19 can probably expect a more severe infection, health experts warn. Many advisories have focused on the risk facing older people, those with chronic conditions such as diabetes. and people with compromised immune systems, such as cancer patients. But doctors also caution that users of electronic cigarettes and tobacco are more in danger from the new coronavirus than the average healthy person."
As several experts in disability law (including Professor Banzhaf) have pointed out, federal law (especially the Americans With Disabilities Act [ADA]) and most state laws prohibit discrimination against persons because of their disabilities - which could include patients with diabetes, cancer, and weak immune systems - so it appears that such medical conditions cannot legally provide the basis for limiting their access to scarce ventilators, even if they substantially reduce their chances of survival.
However, notes Banzhaf, there is no federal or state law which protects smokers - because smoking, or even nicotine addiction, is not regarded as a "disability" - so denying them ventilators during an unprecedented crisis shortage because they are less likely to survive if provided with one is not necessarily illegal, and appears consistent with long-standing medical precedent in other situations.
